Testosterone & ED for Men — Health Questionnaire

About you

We need this to ship your medication and verify your identity.

First name Last name Email Phone Date of birth Biological sex

Shipping address

Street address Apt / Suite (optional) City State ZIP

General health history

Basic background the physician needs to review.

Height (feet) Height (inches) Current weight (lbs) Target weight (lbs)

Current medications (include dose if known — separate with commas) Drug or food allergies Major medical conditions (current or past)

Testosterone & ED screening

A few targeted questions so the physician can evaluate you safely and completely.

Symptoms you are currently experiencing (select all that apply — at least one required) Low libido / loss of drive Erection quality decline Persistent fatigue Mood swings or irritability Brain fog Loss of muscle mass / strength Increased body fat Poor sleep / sleep apnea symptoms Slow recovery from workouts

Have you been diagnosed with sleep apnea, OR do you snore + wake unrefreshed + have witnessed breathing pauses? Diagnosed with sleep apnea Suspected (multiple symptoms present) No

Have you used testosterone or TRT before? No Yes, currently using Yes, previously used

Have you ever been told your hematocrit was elevated or required blood donation / therapeutic phlebotomy?

⚠ TRT can elevate hematocrit, which requires monitoring.

Yes No Unsure

Have you had an abnormal PSA, prostate cancer, or any prostate condition?

⚠ Baseline PSA and ongoing monitoring are required on TRT.

Yes No Unsure

Are you planning to conceive in the next 12 months?

Note: TRT can suppress fertility. Alternative protocols are available if conception is planned.

Yes No Unsure

Erection quality Normal Occasional difficulty Frequent difficulty Unable to achieve adequate erection

Have you used sildenafil (Viagra), tadalafil (Cialis), or other ED medications? No Yes, tolerated well Yes, with side effects

Heart attack, stroke, or coronary stenting in the past 6 months?

⚠ Recent cardiac events within 6 months are a contraindication for sildenafil / tadalafil. Physician review required.

Yes No

Anything else the physician should know? (optional)

Your program

One program — comprehensive evaluation and treatment for testosterone and ED at the same visit.

Testosterone & ED Program (Men)

TRT + ED Evaluation

Telemedicine TRT consult + full hormone panel labs. Physician evaluates testosterone replacement and PDE5 inhibitor (sildenafil/tadalafil) candidacy at the same visit. One consult, potentially two scripts.

$249 first month

After your first visit, your subscription continues at $129/month covering ongoing medication, monitoring labs at month 3 and 6, and as-needed follow-ups.

Save your payment method

⚡ Your card will not be charged today. Your payment method is saved securely with Stripe. After your physician consult, the $249 first-visit charge will be processed, and your $129/month subscription will begin afterward.

By continuing you authorize My4MLife and our network physicians to use this saved payment method to process the $249 first-visit charge after your consult, and to charge your $129/month subscription thereafter. You can cancel anytime by emailing support@my4mlife.com.

Review and submit

Confirm everything looks right. After submission, our care coordinator will email you within 24 hours to confirm next steps with the network physician.

I attest the information above is accurate to the best of my knowledge. I understand a real physician will review my submission, and that no medication will ship without a written script. I authorize My4MLife and the network physician to contact me by email or phone. I acknowledge I have received and reviewed My4MLife's Notice of Privacy Practices. I authorize My4MLife and its network physicians to use and disclose my health information to provide, coordinate, and bill for my care, including forwarding my intake to the telemedicine provider, as described in the Patient Authorization & Telehealth Consent.

✓

Your submission is in.

Our care coordinator will email you within 24 hours to confirm the next step with the network physician. Your card has been saved securely with Stripe — no charge has been made. The $249 first-visit fee will be processed after your consult.

Questions? Email support@my4mlife.com.

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Let's get you matched with a physician

About you

Shipping address

General health history

Testosterone & ED screening

Your program

TRT + ED Evaluation

Save your payment method

Review and submit

Your submission is in.